THE RELATIONSHIP BETWEEN MINI NUTRITIONAL ASSESSMENT SCORE AND INSOMNIA SEVERITY
IN OLDER ADULTS
Pinar Soysal1, Lee Smith2, Ozge Dokuzlar3, Ahmet Turan Isik3
1Department of Geriatric Medicine, Bezmialem Vakif University, Faculty of Medicine, Istanbul
2The Cambridge Centre for Sport and Exercise Sciences, Anglia Ruskin University, Cambridge, United Kingdom
3 Department of Geriatric Medicine, Faculty of Medicine, Dokuz Eylul University, Izmir, Turkey.
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ABSTRACT
OBJECTIVES: Both insomnia and malnutrition are quite common, and can cause similar negative
consequences, such as falls, depression, and cognitive impairment in older adults, but there is no
study investigating the relationship between the two.The aims were to investigate relationships
between insomnia/insomnia severity and Mini Nutritional Assessment score, and serum nutrients
levels.
SETTING AND PARTICIPANTS: Aged 65 years or older, 575 outpatients were included.
METHODS: MNA >23.5, 17-23.5, <17, were categorized as normal nutritional status, malnutrition
risk, and malnutrition, respectively. Serum vitamin B12, vitamin D and folate deficiencies were also
evaluated. Insomnia Severity Index (ISI) with scores of 8 and higher, indicated insomnia, which was
further stratified according to ISI score as mild (8-14), moderate (15-21), or severe (22-28).
RESULTS: The mean age was 73.1 ± 7.7 years, with 73.2% being female. The prevalence of patients
with no insomnia, mild insomnia, moderate insomnia and severe insomnia were 34.4%, 20.9%,
30.1%, and 14.6%, respectively. After adjusting for gender,education, number of drugs, Charlson
comorbidity index, presence of depression, and Mini-Mental State Examination scores, patients with
insomnia had lower MNA scores than those without insomnia (OR=0.84, 95% CI: 0.7-0.9,
p<0.001).There were significant relationships between moderate/severe insomnia and the presence
of malnutrition and risk of malnutrition (OR=1.6, 95% CI: 1.0-2.5, p=0.046 / OR=1.6, 95% CI:1.0-2.7,
p=0.042) and MNA scores (OR= 0.83, 95% CI:0.7-0.9, p<0.001) / OR=0.82, 95% CI:0.7-0.9,
p<0.001).There was no significant difference between insomnia severity status and serum vitamin D,
Vitamin B12, folate levels or classification of these nutrients (p>0.05).
Conclusions and Implications: There is a close relationship between MNA scores and
insomnia/insomnia severity in older adults. Therefore, when evaluating an elderly patient with
insomnia, malnutrition should be evaluated, or insomnia should also be questioned in an elderly
patient with malnutrition. Thus, more effective management of the two can be possible.
Keyword: insomnia; mini nutritional assessment; micronutrient; nutrition; vitamin D; vitamin B12;
folate
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INTRODUCTION
Insomnia is defined as persistently having difficulty in initiating and sustaining sleep, or waking up
too early in the mornings and not falling asleep again. (1) While the prevalence of insomnia is 12% -
20% in the general population, the prevalence rate of insomnia symptoms ranges from 30% to 48%
in the elderly. (2) In a study of 6,899 older adults aged 65 years and over, the incidence of annual
insomnia was found to be 7%, and it has been reported that some drugs (e.g., beta blockers) and
comorbidities such as chronic pain, depression, cancer, chronic obstructive pulmonary disease,
cardiovascular diseases, and some other factors, such as inactivity, decreased social relationships
and caregiving, are increasingly associated with insomnia. (3) On the other hand, regardless of all
these and similar factors, aging-related circadian rhythm disturbances can contribute to the
development of later-life insomnia, such as changes in the amplitude of the circadian oscillation of
physiological parameters like melatonin or the decrease in the effectiveness of the suprachiasmatic
nucleus in the hypothalamus. (4) If not treated, insomnia can lead to dementia, depression, anxiety,
delirium, diminished quality of life, falls, and cardiovascular diseases such as hypertension,
myocardial infarction, and stroke. (4,5) With the appropriate treatment of insomnia, the
development of such complications can be prevented. However, as well as insomnia, drugs used to
treat it have also a number of side effects. (6) For this reason, the number of studies investigating
the reversible causes of insomnia in recent years has increased.
Both micronutrient deficiencies and malnutrition or malnutrition risk are quite common, and are risk
factors for a variety of negative consequences, such as sarcopenia, frailty, falls, depression, and
cognitive impairment in older adults (7–9). In only a few of these studies, a significant relationship
between micronutrient abnormalities and sleep was shown following the evaluation of the effect of
nutritional factors on insomnia. (10–12) One study found a relationship between low serum vitamin
D levels and short sleep duration and lower sleep efficiency in older men. (11) Another identified a
correlation between vitamin B12, vitamin D and folate deficiency and sleep disturbance. (8)
Moreover, although malnutrition is as important as micronutrient deficiency and is common, to the
best of our knowledge, there is no study investigating the relationship between malnutrition and
insomnia.
Therefore, the aim of this study was to investigate the relationship between Mini Nutritional
Assessment scores/nutrients and insomnia/insomnia severity in the elderly.
Methods
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Patients
A total of 575 older outpatient who were admitted to a geriatric clinic were included in this study. All
the patients underwent Comprehensive Geriatric Assessment (CGA). (13) The investigation
conformed to the Declaration of Helsinki was approved by our local ethics committee. Informed
consent was provided by each participant or a legal guardian before participating in the study.
Patients who had severe illness that may impair their general health status, such as acute
cerebrovascular event, sepsis, acute renal failure, acute coronary syndrome, and acute respiratory
failure; patients under 65 years of age; patients who did not agree to undergo the CGA; patients who
take medication for sleep disorders or who take nutritional supplements for malnutrition or nutrient
deficiencies were excluded. Patients with moderate and severe dementia were also ruled out
because self-reports based on their memory might be unreliable for questions about insomnia and
nutrition, but patients with mild dementia were included.
Patients’ Characteristics:
Patients’ age, gender, education level, and drugs were recorded. Those with hypertension, ischemic
heart disease, congestive heart failure, diabetes mellitus, peripheral arterial disease, chronic
obstructive pulmonary disease (COPD), cerebrovascular disease or Parkinson’s Disease were
identified by their or caregivers’ self-reports. In addition, comorbidity status of the patients was
evaluated using the Charlson Comorbidity Index (CCI). (14) Dementia and depression were
diagnosed according to Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5)
criteria. (15) All the participants underwent the Mini-Mental State Examination, and Geriatric
Depression Scale-15 for neurocognitive evaluation. (16,17)
Nutritional Evaluation
MNA (Mini Nutritional Assessment) was performed in all patients to detect nutritional status, even if
their MNA-Short Form scores were ≥12. If the total score was > 23.5, 17-23.5, <17, it was accepted
as well-nourished, risk of malnutrition, and malnutrition, respectively. The MNA test is composed of
simple measurements and 18 brief questions that can be completed in < 10 min: anthropometric
measurements (4 questions related to BMI, weight loss, brachial circumference, and calf
circumference); Global assessment (6 questions related to lifestyle, medication, and mobility);
Dietary questionnaire and subjective assessment (8 questions related to number of meals, food and
fluid intake, and autonomy of feeding, self-perception of health and nutrition). (18) Due to the
potentially multifactorial origin of nutritional risk in the older adults, the MNA specifically designed
and validated for the olders. Given the multi-dimensional approach, the MNA properly addresses
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this requirement and the prevalence of nutritional conditions provided by the MNA appears in the
measure able to reflect the nutritional features. (19) To calculate body mass index (BMI), height was
measured to the nearest centimeter (cm) and weight was measured to the nearest half-kilogram (kg)
with the same stadiometer.
Assessment of Insomnia
Insomnia Severity Index (ISI) consists of 7 questionnaire items that capture self-reported symptoms
and daytime consequences of insomnia, according to criteria from the Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition. ISI scores range from 0 to 28, with higher scores
indicating more severe insomnia. ISI scores of 8 or higher indicated insomnia, with severity further
stratified according to ISI score as subthreshold (herein termed mild) (8–14), moderate (15–21), and
severe (22–28). (20,21)
Vitamin B12, folate and vitamin D assessment
To evaluate the biochemical evidence of insufficient intake and the metabolic condition, blood
samples were collected in the morning after at least 8 h of fasting. Serum vitamin B12 level was
considered to be deficient and low serum vitamin B12 level when it was below 200 pg/ml and below
400 pg/ml, respectively. (22) Vitamin B12 was also evaluated according to cut-off 150 pg/ml.(23)
Folate deficiency and low folate level were evaluated according to both < 3 ng/ml and 6 ng/ml,
respectively. (7) After blood collection the gel tubes were centrifuged within one hour and the sera
stored at 200C for serum vitamin D analysis. 25(OH) D was measured by radioimmunoassay method.
Patients with 25(OH) D < 10 ng/ml were considered to have vitamin D deficiency, and 25(OH) D=10-
20 ng/ml was accepted as insufficiency. (24)
Laboratory Findings
Laboratory tests were performed to assess biochemical, metabolic, and nutritional status of the
patients included measurements of complete blood count, kidney and liver functions, cholesterol
levels, thyroid stimulating hormone, and HbA1c. All these biochemical tests were performed using
the Diagnostic Modular Systems auto analyser (Roche E170 and P-800).
Statistical Analyses
Data were analysed using SPSS, version 22. Descriptive statistics are shown as mean±standard
deviation for variables with normal distribution, median (minimum to maximum) for non-normal
distributions, and number of cases and percentage for nominal variables. When the group number
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was 2, the significance of differences between the groups in terms of averages was investigated by t
test, and if in median values, was investigated by Mann-Whitney test. When the number of groups
was more than 2, the significance was investigated by analysis of variance and the Kruskal-Wallis test
for averages and medians, respectively. Nominal variables were assessed by the Pearson chi-square
or Fisher exact test. Variances in more than 2 groups were assessed by post hoc Tukey tests. We
used linear regression and logistic regression to analyse associations between sleep status and
nutritional status and MNA scores, adjusted for all covariates including gender, education, number
of drugs, CCI, presence of depression, and MMSE scores. For p <0.05, results were considered
statistically significant.
RESULTS
The mean age of 575 patients was 73.1 ±7.7, 73.2% of them was female and mean education level
was 3.2 ± 1.9. The prevalence of patients without insomnia was (ISI < 8) 34.4%. The prevalence of
patients with mild insomnia, moderate insomnia and severe insomnia were 20.9%, 30.1%, and
14.6%, respectively. There is no difference between the groups in terms of laboratory findings
including kidney and liver functions, cholesterol levels, thyroid stimulating hormone (p>0.05). Table
1 shows demographic and clinical characteristics. There was a significant difference between groups
in terms of gender, education, number of drugs, CCI, presence of depression, and MMSE scores
(p<0.05). The four insomnia severity groups were compared with respect to nutritional parameters,
and lower MNA scores and higher rates of malnutrition and malnutrition risk were detected in
patients with moderate and severe insomnia compared to the patients with mild insomnia or
without insomnia (p<0.001). When groups were adjusted for all covariates, the significant
differences between nutritional status and insomnia severity status persisted (p<0.05). There were
no significant differences between insomnia severity status and serum vitamin D, Vitamin B12, folate
levels or classification of these nutrients (p>0.05).
The relations between nutritional status and insomnia groups were investigated using logistic
regression analysis adjusting for all the covariates. Results showed that there was a statistically
significant relationship between insomnia status and MNA and nutritional status (p<0.05). Their odd
ratios were shown in Table 2. Relationships between insomnia status and MNA and nutritional status
were investigated using multiple linear regression models and are shown in Table 2. There were
significant positive correlations between malnutrition/risk of malnutrition and insomnia/moderate
and insomnia/severe insomnia, whereas insomnia status and MNA scores showed a significant
negative correlation (p<0.05).
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Figure 1 shows the comparison of prevalence of insomnia according to nutritional status (p<0.05).
Discussion
In this study, the relationship between insomnia and insomnia severity and nutritional status was
investigated in the elderly, and MNA scores were found to be lower in patients with moderate and
severe insomnia. Insomnia or moderate to severe insomnia have been shown to be significantly
correlated with nutritional status and associated with low MNA scores. However, for mild insomnia,
this relationship was not detected.
Insomnia is common in older adults, but the prevalence of both insomnia and moderate and severe
insomnia in our study was more frequent than previous studies. (25) In a meta-analysis, the
prevalence of sleep problems was found to be high in low- and middle-income countries and was
associated with depression, low education and low socioeconomic status; which may explain the
high insomnia prevalence in our study. (26) In addition to this high incidence of insomnia, it may be
associated with difficulty in maintaining daily activities, falling, fractures, stroke, physical disability,
dementia, respiratory symptoms and cardiac diseases. (3) Moreover, considering that the drugs used
for the treatment of insomnia in the elderly have numerous side effects, the importance of revealing
the causes of reversible insomnia, which may lead to insomnia, will be better understood. (6)
Malnutrition/the risk of malnutrition, such as insomnia, is one of the most important geriatric
syndromes that may cause complications similar to that of insomnia with increasing age; however,
there is no study investigating how insomnia is affected by nutritional status of patients. In our
study, it was found that MNA scores and normal nutritional status were lower in patients with
insomnia, particularly in patients with moderate and severe insomnia. Possible mechanisms that
explain this may include: Firstly, malnutrition may cause neurodegeneration and white matter
damage, which may impair the regulation of brain functions. (27–29) For example, in previous
studies, dialysis patients with anorexia nervosa and severe weight loss had a higher risk of the brain
atrophy and low fat mass was associated with more white matter hyperintensities (WMHs). (28) In a
study by Marian et al., it was claimed in the elderly that malnutrition may cause WMHs rather than
brain atrophy, which may be explained by malnutrition alone that impairs cardiovascular
homeostasis independently of other cardiovascular risk factors, as in our study. (29,30) Additionally,
malnutrition-related inflammation is another cause of WMHs. (31) In recent years, these WMHs
have been found to cause insomnia by disrupting the integrity between left thalamus and pars
triangularis tracts. (32) In another study, the dysfunctions of white matter structural network
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connectivity in healthy adults were found to be associated with insomnia symptoms. (33) On the
other hand, experimental studies have shown that in rats with malnutrition, the size of the
suprachiasmatic nucleus, which is the most powerful pacemaker for circadian rhythm, has a key role
in sleep physiology, and that sleep deprivation is decreased by energy and nutritional
supplementation. (34,35) Secondly, dietary factors can affect melatonin release. (36) Melatonin is a
circulating neurohormone, which is mainly secreted at night and is produced from tryptophan, an
essential amino acid. (35) It is important to detect the daily light and dark cycle, so that the circadian
rhythm can be regulated and help us fall asleep and stay asleep. (36) There are many studies
showing the effect of diet on the synthesis or concentration of melatonin. For example, it has been
shown in human studies that energy restriction decreases the release of melatonin at night. (36-38)
In short-term (2 days) fasting healthy men, melatonin secretion was decreased compared to the
control group, and normalization of melatonin levels were found after glucose supplementation. (38)
Similar studies have been made in obese and the same results have been obtained. (40) Thirdly, in
patients with malnutrition, Orexin, a neuropeptide released from the hypothalamus to increase
nutrition, also increases alertness. (41) Accordingly, a large number of studies have shown that sleep
is adversely affected in patients with anorexia and bulimia nervosa compared to those without;
therefore, sleep is thought to be a clinical marker for eating disorders . (42) Orexin neurons “fire”
with circadian rhythm; thus, orexin levels increase during periods of wakefulness, whereas serum
rates of Orexin decrease during sleep. A recent study demonstrated that plasma orexin levels were
higher in patients with insomnia than those without insomnia. (43) Orexin receptor antagonists also
were shown to improve sleep, and might be potential pharmacologic agents for treatment of
disordered eating in humans. (44,45) However, further research is necessary to address this issue.
Lastly, insomnia itself may also affect dietary behaviors and intake. (46) For example, decreased
appetite for heart failure patients was associated with insomnia. (47) On the other hand, decreased
sleep time may also help to explain the cause of worsening nutrient status by increasing insomnia
severity. (48) However, future studies utilizing a longitudinal or experimental design are needed to
establish the accuracy of all these hypotheses.
Our study is the first to investigate insomnia severity and nutritional status in the elderly. So far,
correlation between malnutrition and insomnia was vaguely mentioned in studies investigating
geriatric syndromes associated with malnutrition in the elderly, but this correlation could not
elaborately be evaluated because they were not aimed for this purpose. (49,50) Although some
studies have shown that vitamin B12, folate and especially vitamin D may cause insomnia (10,11), it
is unclear whether this relationship is due to malnutrition or indeed nutrient deficiency, since none
of these studies concurrently have nutritional status assessed.
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The strengths of our study are: the number of adequate samples; grading not only the presence of
insomnia, but also the severity of insomnia; MNA-long form applied to all patients; simultaneous
evaluation of both nutritional and vitamin B12, folate and vitamin D. However, our study is not
without limitation. First, the present study was cross-sectional in design and the direction of the
association is not known. That is, it is not known whether insomnia leads to poor nutritional
parameters or whether poor nutritional parameters lead to insomnia. It is possible that the
relationship is bidirectional. Future research of an experimental prospective design is now needed.
Second, only the insomnia severity index scale was used for insomnia, future studies should consider
using objective measures of sleep to diagnose insomnia, such as actigraphy. Third, the correlations
between MNA items associated with food intake or weight/weight loss variables and insomnia were
not evaluated. Last, the number of patients with folate deficiency was so low that it was not able to
be analysed.
Conclusions and Implications
In conclusion, there is a close relationship between insomnia and insomnia severity and nutritional
status in the elderly. Especially in patients with moderate and severe insomnia, MNA scores are
lower. Therefore, when evaluating an elderly patient with insomnia in geriatric practice, malnutrition
should be evaluated or insomnia should be questioned in an elderly patient with malnutrition. Thus,
more effective management of the two will be possible.
Acknowledgements
Conflicts of Interest: No conflicts of interest for all authors.
There is no funding.
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Table 1. Demographic and Clinical Characteristics Insomnia StatusInsomnia Severity Index (No=575)
Characteristic No insomnia(198)
Mild insomnia
(120)
ModerateInsomnia
(173)
Severe insomnia
(84)p value
Age (years) 72.9±7.8 72.1±7.2 74.2±8.0 72.8±7.8 0.151*Gender (Female, %) 60.6 78.3 80.9 79.8 <0.001*Education (years) 4.5±3.9 3.3±2.9 2.5±3.4 2.6±3.2 <0.001*CCI 0.8 ±1.1 0.8±0.7 2.2±9.3 1.1±1.6 <0.05*Number of Drugs 3.7±2.6 4.4±2.6 4.3±2.6 5.1±3.3 0.005Obesity (%) 59.1 65.0 57.8 57.1 0.338COMORBIDITIES (%)Cerebrovascular Events 6.1 1.7 6,9 7.1 0.170Diabetes Mellitus 31.8 39.2 37.0 32.1 0.493Ischemic Heart Disease 12.2 15.8 15.0 16.7 0.709Congestive heart failure 4.5 4.2 7.0 9.5 0.304Hypertension 67.2 69.2 69.4 64.3 0.848COPD 9.6 10.0 12.7 19.0 0.134Osteoarthritis 22.2 26.7 30.6 25.0 0.326Parkinson's disease 3.5 5.0 6.4 7.14 0.078Dementia 5.1 3.3 5.2 7.1 0.903*Depression 38.6 35.6 59.2 62.3 <0.001*MMSE 25.6±3.2 24.6±4.4 22.9±5.4 23.8±3.8 <0.001Nutritional Determinants*Nutritional Status
Malnutrition 1.5 5.8 10.4 7.1 <0.001** Risk of Malnutrition 22.7 30.0 43.4 52.3 Well-nourished 78.8 64.2 46.2 40.6
MNA scores 25.4±3.0 24.4±3.4 22.7±4.0 22.6±3.3 <0.001**Classification of Vitamin D (%)
≤ 10 ng/ml 34.3 49.2 42.8 38.10.266 10-20 ng/ml 24.2 18.3 22.0 32.1
>20 ng/ml 41.5 32.5 35.2 29.8Serum Vitamin D levels 20.7±16.7 18.0±11.7 17.0±11.7 18.1±12.9 0.709Classification of Vitamin B12 (%)
<200 pg/ml 14.1 13.3 15.0 12.20.934 200-400 pg/ml 48.0 42.5 46.8 50.0
>400 pg/ml 37.9 44.2 38.2 37.8o < 150 pg/mL 21.2 18.3 17.3 16.7
0.793o ≥ 150 pg/mL 78.8 81.7 82.7 83.3Serum Vitamin B12 levels 267.3±157.2 229.4±119.3 277.1±158.0 267.
4±166.50.098
Serum Folate Levels 8.7±3.6 9.0±3.2 8.9±3.2 9.6±4.1 0.518Classification of Folate (%)
Folate < 3 ng/ml 3.2 1.7 1.9 2.5 NACCI: Charlson Comorbidity Index; MMSE: Mini Mental State Examination; NA: Not Applicable
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402
*The parameters were significantly different between patients with insomnia (≥ 8 ISI score) and control group (< 8 ISI score)
** After adjustment for gender, education, number of drugs, CCI, presence of depression, and MMSE scores, p value was still found significant (p< 0.05)
NA: Because the number of patients with folate deficiency was so low that it was not able to be analyzed
403404
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Table 2. Associations Between Nutritional Status and Insomnia Severity Status
Insomnia Mild Insomnia Moderate Insomnia Severe Insomnia
Logistic RegressionOR (%95 CI) p OR (%95
CI)p OR (%95 CI) p OR (%95 CI) p
Malnutrition andRisk of Malnutrition
1.6 (0.9-2.7) 0.070 1.8 (0.8-4.1)
0.124 1.6 (1.0-2.5) 0.046 1.6 (1.0-2.7) 0.042
MNA scores 0.84 (0.7-0.9) <0.001
0.9 (0.8-1.0)
0.051 0.83 (0.7-0.9)
0.000 0.82 (0.7-0.9)
0.001
Linear RegressionBeta p Beta p Beta p Beta p
Malnutrition 0.348 <0.001
0.135 0.39 0.508 <0.001 0.440 0.02
Risk of Malnutrition
0.213 <0.001
0.097 0.12 0.261 <0.001 0.304 0.04
MNA scores -0.285 <0.001
-0.022 0.09 -0.358 <0.001 -0.383 <0.001
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